30 OUTLOOK AVE - BUILDING INSPECTION (2) l
'j RECEIVED
INSPECTIOi.r L SERVICES �6
P1 Li.� Ned c os°I
/1 ie ton ve Il of ibiassachusetts CITY OF
r./ i Board of Building Regulations and Standards SALEM
4((� Massachusetts State Building Code, 780 CMR Revised,t.hir1oll
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
n This Section For Official Use Only
Building Permit Number. te:Applieds
Building Olficiul(Print Nume) _ Signatures. Dale
( SECTION I:SITE INFORMATION
11� I.1 Property it
1.2 Assessors Map Fr Parcel Numbers t
30- OuTL�oK �}VE SII Larn
I a Is this an acce led street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zuning District -Proposed Use - Lnt Area(sq 11) Frontage(11) .-
1.5 Building Setbacks(R)
Front Yard - Side Yards - Rear Yard
Required ., Provided -Required Provided. . Requited " Provided
1.6 Water Supply:(M.G.L c.40,§54); 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private O If
Zone: Outside Flood Zone? Munici O On site disposalsystem O
. — Check bsO �
SECTION2. PROPERTY OW
2.1.Owner t of Record:
n/ D(Z i Sl4L�!'h N1 {�SS
me 0(Print) - City,;State,ZIP
3lr®t/T Imo ��r liu_L I yY
No.and Street ' - Telephone Email Address V.
SECTION 3:DESCRIPTION OF PROPOSED WORK4(check all that apply)O ❑
New Construction Existing Building Owner-Occupied O Repairs(s) ❑ Alteration(s)tion(s) Addition ❑
De
molition O Accessory Bldg.O Number of Units_ Other ❑ Spedly:,S'_9JL/>b
Brief Description of Proposed Work-:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
It cat Estimated Costs: Official Use Only
Labor and Materials
I. Building S 7 6OQ, 00 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical S 0 Total Project Cosh(item 6)x multiplier x
1. Plumbing S 2?Qther Fees: S
d.Mechanical (FIVAC) S List:
5.:Mechanical (Fire Suppression) S 'total All Fees:S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S �OQ 690 ❑Paid in Full ❑Outstanding Balance Due:
C6 a�r� (nfa t t r> %+A
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
1 k License Number Expiration Date
Name9 of CS`L Holder List CSL Type(see below)
Type - Description ., .
No. and Street ..
� � „^ 0 U Unreslricted DuilJin to 35,000 cu. R.
rYl / 7 R Restricted )&2F:uni1 LipDwellin
Cityrrown,State,ZIP M masonry
RC Roolin Coverin
WS Window and Siding
a SF Solid Fuel Burning Appliances
1 I Insulation
Tcic hone Email address I D I Demolition
�5..2� Registered Home ImprovementContractor(HIC) y 12
y(/y( -T '/�1.IQ I/ 4,;T 7A / HIC Registration Number Expiration Date
II C Company Name or 111C Registrant Name
% ti- yF)Lan->a sTR0�'T
�T
oym'f'_ n
Street pf ? r!�)�.1 Email address
//� 'v T / I
Cit /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c.152:$ 25C(6)) .
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION lap OWNER AUTHORIZATION TO BE.COMPLETED WHEN'
OWNER'S AGENTOR CONTRA\CT�OR APPLIES FOR�BgUIIpLDIIN[�G PPER..,McIT
1,as Owner of the subject property,hereby authorize t'V l-C 1-tIg r 1 ! /�-T�i`'G�'J' -
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Ptly cKwAlOR 1l- a-)s
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
fa -, 11 - ma's
Print Owner's or Authorized Agent's Name(LUctrome Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
_ (not registered in the Home Improvement Contractor(HIC)Program),will no have access to the arbitration
2—--- --— -
program or guaranty fund under NLG.L.c. 14_A.Other important mformafion on the H1C Program can be�tound�--- --- -- --
www mass.eov'oea Information on the Construction Supervisor License can be found at www.mass.eo�-'dns
2. When substantial work is planned,provide the information below:
'rota) floor area(sq. ft.) N (including garage,finished basementlattics,decks or porch)
Gross living area(sq. it.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
rype of heating system Number of decks/porches
'rype of cooling systeIn Enclosed Open
]. "rotal Project Square Footage"may be substituted ror"'rued Project Cost"
r
.Page'f o. t. of Pages
y _
WM. TRAHANT JR;'CONSTRUCTION,ZINC.
4TH GENERATION ROOFING
215 Verona Street
LYNN, MASSACHUSETTS 01904 CSL#101220
(7&1) 599-1211 •-(781) 844-4551 • FAX: (781) 581-0855 H.I. LIC. #141778
PROPOSAL SUBMITTED TO - - - PHONE - DATE
t ennQr � � awq' iyeao 7- ao rs
STREET �J NAM
t-oo�;. AJe �1 �b 740 60yl05-
CITY,STATE and ZIP CODE _ JOB LOCATION
IE: .
We hereby submit specifications and estimates for: - - We hereby submit specifications and.estimates for:
SHINGLE ROOF FLAT/RUBBER ROOF
Strip entire roof ❑ Reshingle ❑ Sweep entire roof clean
place any bad boards up to 100 linear feet El Strip..entire roof
_ Inst,II Ice and water barrier first t1 ree feet up roof ❑ Mechanically fasten down ISO board insulation —
nstall ice and water barrier in all valleys and along dormers ❑ insfall 060 Rubber Roofing on entire roof
jj pus-fry
nstall �9ef`on remainder of roof ,`--- -❑ Install metal flashing around perimeter of building _
Install eight inch drip edge n White ❑ Black `❑ Mill :'❑ Flash chimney(s), pipe(s) and wall(s) .
nstall ricl&vent a ❑ Edge caulk all seams
lash or re-flaSh chimneys) �T.qjS l I_or-w�V_Ab ❑ Install new copper center drain - - --
nstall new pipe flanges ❑ Other:
Install lifetime shingle COlor Sit rk woo ❑ Cleanup all debris
-= vt. — --------- — ------- ---- - =------- --- -- -- -- =---
Irt l gutters and downspouts '❑ Labor and materials guaranteed 100%for five years
❑ Install trim coil
❑ Install new fascia boards
❑ Install new rake boards a
❑ Install skylight(s) ' r8"'r'T d�
V ®�-0.6-V ---- -- -
❑ Other. -
1:;i�6ean up all debris `_■'e,.l—
Cb"La r and materials guaranteed 100%for five years
All shingle roofs are nailed.by hand.
4.
Pe Vru)xmse hereby to furnish material and`labor - complete in accordance with aVove specifications for the;sum of:
. _ y Total Price($
- **IF -YOU -ARE:HAVING YOUR, ROOF STRIPPED, PLEASE COVER ALL VALUABLES IN; ATTIC, AS
pp WE-,HAVE NO' CONTROL OVER DEBRIS THAT-MAY -FALL THROUGH ROOF BOARDS.""'
All material is guaranteed to be as specified.All work to be completed in aworkmanlike
manner according to standard practices. Any alteration or deviation from above specs ica Authorizes -
tions involving extra costsswill be executed only upon written orders, and will become.an Slgnatur
extra charge over and-.above the estimate. All agreements Contingent upon strikes,
accidents or delays beyond our control.Owner to carry fire,tornado; and other necessary - -
insurance.Our workers are ffully covered by Wdrkman's Compensation Insurance...
-�CCeptance DfPTOposal--The above prices,specdlcatlons
t
and condditio is are satisfactory and are hereby accepted.You are authorized to ! Signature
do the work as specified.Payment will be made as outlined above.
Date of Acceptance- _ Signature ---�✓"-"�-
mmv Please mail yellow coot'to above address. - L_.
The Commonwealth ofMassaehusetls
Department oflndustiiWAccidents
1 Congress Street,Suite 100
Boston,MA 02.714-2017
www.ma=gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Elechicians/Plumbers.
TO BE Fn.ED WITH THE PERMTII ING AUTHORITY.
Applicant Information
y Please Print Igelbly
Name(Busmess/Orgamaetiontindividnal): 1,/�-t'} /1'1.. y 3�. ('4oy 7' r
Address: �L) Vf 7`PO AIA. 9TI�56 7�p
City/state/Zip: L,1n/L/p/ Dl�a if Phone#:
Are you an employer':Chte the appropriate box:
Type otproject(required):
1.o I am a employer whli employees(full ind mpart-time).- 7. ❑New con6'huchon
2.p loan a sole proptietm m parmer"and have no employees wolking forme in 8. 0 Remodeling
any capacity.[No winkeis'comp'ivsuance rewired] -
3.p 1 am a homeowner doing as work myself.[No workers'comp.insurance raryked]t 9. Demolititm
4.E]I am a homeowner and will be hiving contractors to conduct All work on my property. I will 10 O Budding addition.
ensure that all contracos either have workers'compensation m�s�^.t m are sole 11.0 Electrical repairs Or additions
propnetma with no employees. 12. Plumbingof additions
5.p i am a general contractor and Ihaw lived the suDiontiueton listed on the ad sheet. O s
lbmmib:conbactmbaveemploye mdhave workAre comp.ier �mmt 13.QRoofr/p!-a7�ry�
6.p We are a corporation and its officers have exercised theirright of exemption perMGL C. 14.p Other
15Z§I(4),and we have no employees.[No workers'comp:insurance mquired.] - -
'Any applicant that checks box##must also fill our the section below showingtbeaworkea comremetwo policy mfgiulwm.
t Homeowners who submit this atfidmt indicating they are doing all work and then hive outside comsagors most submit a new Affidavit ixficanng such
tContractors that check this box must attached an additional shed showing the name of the sub-conmMms and state whether m not those entities have -
employees. Iftbe subcont boon;have employees,they,must provide their workers:-comp.policy numbor. .
lam an..employer htsprovldin workers'com pnadoninsrrancejormyemployeex Belowisthepoliryandjob site
Instuance Company Name: /� r t
Policy#or Self-ins.Lic.#: V>^�5a -_( G /�' C7��g p• (Lt/ Expiration Date. I° 0q-IL
Job Site Address: ✓��O uT o 0 I r E GSty/State/Zip:s lL m
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to S 1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up.to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby��cenify under thepains sangd7p�e/n�altiess ojpeerrjurr�y that the information provided above is true and correct
Signature: W..t.P,�l.r8.t: fli u""e 4+Y Date: 1 1—�N
Phone#: / a/_S C 1 _ ):2-1(
Ojrwiaf use only. Do not write in this area,to be completed by airy or town offiieW
City or Town: PermWUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartrnents and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insuaance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(I.I.P)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may,be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and primed legibly. The Departrnent has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
Cr7y of SALEg MASSAausE m
BumDnaGDEPARnew
120 WASIMYGNOISTREET,YDROOR
TEL(978)7454595.
BIIvJ6ERLEYDRiSODLL FAX(978)740-9846
MAYOR IMUMS STMEW
DntEcrcataePua cPRcnm/BI wmcommmomR
Construction Debris Disposa/Affidavit
(required for all demolition and,renovation work)
in accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL coo,S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of appqicant
Date
y u
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supen isor Specialty -
License: CSSL 101220
' WII,LIAMR �
215 NiA STRE
LYNNMA got
r ,c
Expiration
Commissioner 02/10/2016 ,
f �-\ Office of Consumer Affairs&Business Regulation
I MEIMOVEMENT CONTRACTOR
txe,gIhstZloRn. -T8945Type:
;
piration �6/�D16 Corporation
WILLIAM TRAHANYiJRT NC`
�. - WILLIAM TRAHANT�g�
215 VERONA ST
LYNN MA 01904 - Undersecretary